People have always used drugs to alter health, perceptions, relationships and state of mind
The criminalisation of people who use certain drugs increases levels of stigma, encourages misinformation and contributes to harms, including high rates of preventable deaths.
Countries that have implemented comprehensive harm reduction programmes have managed to turn around epidemics of HIV and hepatitis C virus (HCV) infection. Overdose deaths are lower in contexts where harm reduction services are in place, compared with places where they are not. Harm reduction reduces the adverse health, social and economic consequences of drug use without necessarily reducing drug consumption.
Harm reduction refers to policies, programmes and practices that aim to minimise negative health, social and legal impacts associated with drug use, drug policies and drug laws. Harm reduction is grounded in justice and human rights – it focuses on positive change and on working with people without judgement, coercion, discrimination, or requiring that they stop using drugs as a precondition of support. Harm reduction encompasses a range of health and social services and practices that apply to illicit and licit drugs. These include, but are not limited to, drug consumption rooms, needle and syringe programmes, non-abstinence-based housing and employment initiatives, drug checking, overdose prevention and reversal, psychosocial support and the provision of information on safer drug use. Approaches such as these are cost-effective, evidence-based and have a positive impact on individual and community health. (Harm Reduction International).
Harm reduction is an evidence, rights and public-health-based approach that reduces risks and improves the health and well-being of people who use drugs and the broader community.
Long-term policies and interventions are needed to address structural factors that contribute to harms related to drug use.
South African policy.
South African health policy supports evidence-based interventions for people who use drugs. For example, the
TB, tuberculosis; STI, sexually transmitted infection; OST, opioid substitution therapy; WHO, World Health Organization.
Harm reduction principles for healthcare settings are listed.
The application of these principles can improve patient–clinician relationships. The impact of harm reduction is increased through community engagement and peer-led services as well as removing barriers and increasing support.
Harm reduction is an evidence, rights and public-health-based approach that reduces risks and improves the health and well-being of people who use drugs and the broader community.
Depending on the drug, 8% – 15% of people who use drugs develop a problem with their use. Drug use occurs along a continuum and can shift according to various factors (see
Patterns of drug use.
| Pattern of use | Description |
|---|---|
| Experimentation | Most young people will experiment with some activity that is outside of socially acceptable norms. Drugs are one of the ways people experiment. Most people will experiment for a limited period and then stop. |
| Non-dependent adult use | Many people consume alcohol in this way – it is used for social events, and largely remains non-problematic. Many people will use unregulated drugs in the same way. |
| Conscious, regulated use | Many drugs are used only in certain ways and circumstances, according to a set of cultural or individual rules and accepted norms. Cannabis use by Rastafarians is an example, as is the planned use of hallucinogenic drugs to find answers to a specific problem. When someone makes a well-informed conscious choice to use a specific drug in a specific way in specific circumstances, it will seldom become problematic. |
| Dependence | The International Classification of Diseases and Related Health Problems (ICD) version 11 (ICD-11) defines this as ‘a disorder of regulation of [specific drug] use arising from repeated or continuous use of [specific drug]. The characteristic feature is a strong internal drive to use [specific drug], which is manifested by impaired ability to control use, increasing priority given to use over other activities and persistence of use despite harm or negative consequences. These experiences are often accompanied by a subjective sensation of urge or craving to use [specific drug]. Physiological features of dependence may also be present, including tolerance to the effects of [specific drug], withdrawal symptoms following cessation or reduction in use of [specific drug, notably with opioids], or repeated use of [specific drug] or pharmacologically similar substances to prevent or alleviate withdrawal symptoms. The features of dependence are usually evident over a period of at least 12 months but the diagnosis may be made if [specific drug] use is continuous (daily or almost daily) for at least 1 month.’ |
| Habituated use, commonly called addiction | When someone appears to have little control over their drug use and they have learned to use drugs as the automatic response to problems they face or this use is how they can feel alive and engaged, such use can become problematic to the individual and those around them. Habituated drug use is also often dependent. This form of use is commonly called ‘addiction’. Addiction applies to an all-consuming relationship with a drug, person or activity to the detriment of the individual. |
Drugs can be taken by different administration modes, which can lead to different effects and varying degrees of harm. For instance, intravenous (IV) administration is associated with rapid onset and peak of action, with elevated risks: for opioids, this includes overdose and for stimulants, such as cocaine, this includes arrhythmia. Common methods of drug use are summarised here.
Drugs can be categorised into five broad classes according to their primary effects: stimulants, depressants, hallucinogens, cannabinoids and antipsychotics. An overview of common drugs is given in
Overview of common drug types.
| Category | Description | Common examples |
|---|---|---|
| Stimulants | Also known as ‘uppers’, these drugs increase energy. | Caffeine, cocaine, methamphetamine ( |
| Depressants | Also known as ‘downers’, these drugs decrease brain activity and tend to have a calmative effect, making people feel relaxed and drowsy and sometimes leading to a state of lucid dreaming | Sedative hypnotics (e.g. alcohol, barbiturates and methaqualone [mandrax ]), narcotic analgesics (morphine), heroin ( |
| Hallucinogens | A diverse group of natural and synthetic drugs that alter consciousness, perception, thinking and can cause auditory and visual hallucinations. | Lysergic acid diethylamide (LSD), psilocybin (magic mushrooms), 3,4-methylenedioxymethamphetamine (MDMA, |
| Cannabinoids | The flowering head of the cannabis plant. The flowers can be processed into resins (e.g. hashish) and oils or dried and smoked or turned into edibles. It is used to treat nausea, pain, loss of appetite and spasticity. Cannabidiol (CBD) can also act as an antipsychotic, |
CBD and THC |
| Antipsychotics | Used mainly for the treatment of psychotic disorders. They are seldom used outside a medical setting as there are unpleasant side effects that outweigh the benefits for people without a diagnosis of a psychotic disorder. | Quetiapine, olanzapine and risperidone |
CBD, cannabidiol; GHB, gamma-hydroxybutyric acid; LSD, lysergic acid diethylamide; MDMA, 3,4-methylenedioxymethamphetamine; THC, tetrahydrocannabinol.
, Methamphetamine and methcathinone are part of the large group of amphetamine-type stimulants.
As a result of the illegal nature of drug use and associated stigma, obtaining robust data on drug use is difficult and data are limited (see
Myths about drug use.
An excellent resource on myths about drugs and drug use is available at:
Heroin has many names.
Image and performance-enhancing drugs.
Anabolic steroids, peptides and hormones are examples of drugs that may be linked to appearance, the pursuit of health and youth, or a body image disturbance. Patterns of use may vary, with potential health risks related to the substances used, as well as the method of use (e.g. safe injecting or not).
Drug, (mind-) set and setting.
The effect of a drug is not a predictable chemical cascade. Even when the same person takes the same drug, in the same dose, the results may differ depending on a number of variables.
Overview of substance use epidemiology (latest data).
| Drug | Prevalence of use (%) (15–64 years) | Treatment |
Comments |
|---|---|---|---|
| Heroin | 0.3 – 0.5 |
19 (2 – 34) |
Prevalence of use reflects use for different recall periods. The types of substance used vary by region. |
| Cocaine | 1 |
3 (2 – 8) |
|
| Methamphetamine | 1 |
10 (1 – 28) |
|
| Cannabis | 4 |
30 (22 – 38) |
|
| Ecstasy | ND | < 0.5 |
|
| Opioids | < 0.05 |
ND | Cross-sectional survey amongst first-year university students, reflecting use in previous year. |
| Cocaine | < 1 |
ND | |
| Amphetamine-type stimulants | 8 |
ND | |
| Cannabis | 9 |
ND | |
| Ecstasy | < 1 |
ND | |
ND, no data.
, Reflects proportion of admissions for primary substance at treatment centres registered with the South African Community Epidemiology Network on Drug Use. Data are presented as median and range across regions of the country.
The harms related to drugs are embedded in social and structural circumstances, including stigma, which is often driven by the illicit nature of drug use. For a variety of reasons, the production, sale and use of certain drugs are restricted or highly regulated through international agreements.
The quantification of drug-related harms in South Africa, including HIV and viral hepatitis infections and overdose, is inadequate.
Drug scheduling.
The schedule of a drug determines the level of regulation and access. The WHO Expert Committee on Drug Dependence provides recommendations based on rigorous scientific review to the CND, which then decides on drug scheduling.
CND, Commission on Narcotic Drug; LSD, lysergic acid diethylamide; MDMA, 3,4-methylenedioxymethamphetamine; WHO, World Health Organization.
Restricting access can render drugs more dangerous.
Drugs are influenced by market forces, with supply developed to meet a demand. Restricting access to potentially harmful drugs can make them more dangerous. Quality control is often absent in the illicit drug trade. For example, although diamorphine and heroin are the same drug, street heroin is twice as dangerous as morphine.
Overview of infectious disease prevalence and morbidity amongst people who inject drugs (latest data).
| Health issue | Mozambique (%) | South Africa (%) | Comments |
|---|---|---|---|
| HIV | 46 |
21 (8 – 56) |
HIV prevalence estimates amongst people who inject drugs in South Africa from major metropolitan areas |
| TB | ND | ND | |
| STIs | 8 – 29 |
ND | Self- reported genital ulcer |
| HCV | 67 |
55 |
|
| HBV | 32 – 36 |
5 |
|
| HIV–HCV coinfection | 12 – 45 |
9 – 57 |
Includes HBV or HCV co-infection |
| Number of drug-related deaths | ND | 10 |
Ten drug-related deaths included in the formal surveillance system, reported in 2012 |
| Mental health | ND | ND | Between a quarter and half of patients with an opioid use disorder in public in-patient substance use treatment centres have been found to have co-occurring mental illness |
HBV, hepatitis B virus; HCV, hepatitis C virus; STIs, sexually transmitted infections; TB, tuberculosis; ND, no data.
The reasons why people are using drugs outside of supervised medical care are poorly understood. The dominant discourses to explain this phenomenon are often based on moral or political foundations rather than science. It is beyond the scope of these guidelines to provide a comprehensive analysis of the use of drugs. People use drugs for a range of reasons (
Insights into reasons for drug use amongst people with unstable housing, South Africa (2015).
| Reasons | Comments |
|---|---|
| Trauma and loss | ‘I grew up in an abusive family, being sexually abused by my grandfather and having alcoholic parents.’ |
| Exclusion from society and connection with other people who use drugs | ‘When my family rejected me because of my gender of being a transwoman, I started hanging out with people who used.’ |
| Self-preservation and self-medication | ‘I have got to the point where I no longer consider what I am using to be drugs – it is now a medicine.’ |
Chronic problematic drug use is largely caused by personal, social, cultural and political pain and suffering (and at times may also include psychological, physiological and legal issues).
Overlapping vulnerabilities and intersectionality.
Many people engage in multiple activities that may increase their risk of being exposed to HIV, STIs and viral hepatitis, as well as onward transmission of these infections (e.g. someone who injects drugs and also sells sex, or a man who has sex with other men and uses drugs in the context of sexual encounters). Furthermore, some of the vulnerabilities that are related to social constructs may interact and compound risk. Clinicians should avoid stereotyping people and openly enquire about gender identity, as well as sexual and drug-using practices.
STIs, sexually transmitted infections.
Harm reduction case studies.
OST, opioid substitution therapy; SRH, sexual and reproductive health.
It will take a long time to affect a significant reduction in the number of drugs used, and the harms caused because this requires structural reform, which is explored later. The historical focus on abstinence and law enforcement has been ineffective and resulted in significant harm. Harm reduction is an effective public health intervention. It keeps people alive and reduces drug-related morbidity. For individuals, harm reduction aligns with the tenets of medical ethics in that it is beneficent and patient centred. It takes a longer-term view and helps people meet their goals in a stepwise manner. Specific harm reduction interventions relevant to people who use drugs are covered in the section ‘Evidence-based interventions’.
People use drugs for many reasons, in an array of circumstances and contexts and this cannot be modified rapidly.
Not all drug use is harmful.
Addressing drug use in isolation will seldom result in a sustained resolution, unless the underlying motivators are addressed.
People use drugs in different ways; drugs are mostly smoked in South Africa, but injecting is becoming more prevalent.
Drug-related risks and effects depend on the drug, (mind-)set and setting.
The use of opioids and amphetamine-type stimulants in the region is increasing.
In the context of criminalisation, many people who use drugs enter and exit the criminal justice system, placing them at risk for HIV and other infectious diseases.
The burden of HIV, viral hepatitis and TB amongst people who use drugs in the region is high.
Stigma is a process of exclusion; it occurs when a person – or group of people – are tainted or disgraced. When people perceive themselves as being stigmatized, they may also come to hold the same negative perceptions about themselves, leading to an internalization of stigma and acceptance of a ‘spoiled identity’.
Stigma, misinformation and the lack of evidence-based harm reduction approaches are major contributing factors to the vulnerabilities people who use drugs face. Stigma is often not prioritised by healthcare professionals, yet has a profound effect on the relationships between clinicians and their patients.
The use of non-stigmatising language can enhance relationships with patients and clinical outcomes.
The use of non-stigmatising language to enhance patient outcomes.
| Principles | Recommended wording to use | Wording to avoid |
|---|---|---|
|
Separate the person from the behaviour Do not use pejorative terms as a noun Avoid words with a moral or negative connotation Do not use language that vilifies or separates people |
||
, Additional information and responses around drug use and substance use disorders and treatment can be found at:
‘Stigma in health facilities undermines diagnosis, treatment, and successful health outcomes. Addressing stigma is fundamental to delivering quality healthcare and achieving optimal health.’
The International Network of People Who Use Drugs (INPUD) recognises that language cannot be regulated, and that context can transform a term that is used to oppress into one through which emancipation is pursued … Ordinarily, however, language that may denigrate, is best avoided.
Discrimination, which is the enactment of stigma, also needs to be addressed and the rights of all people secured. Many governments in the region have signed the
People who use drugs frequently experience stigma, discrimination and human rights violations, which negatively affect their health and well-being.
The use of appropriate language is an important component of providing support services.
These guidelines are built upon the framework set out in the WHO
Health sector interventions.
| Variable | Description |
|---|---|
| HIV prevention | The correct and consistent use of condoms with condom-compatible lubricants. PrEP should be offered as an additional prevention choice for key populations at substantial risk of HIV infection. PEP should be available to all eligible people from key populations on a voluntary basis after possible exposure to HIV. VMMC should be promoted as an additional efficacious HIV prevention option within combination HIV prevention packages for adolescents aged ≥ 15 years and adult men in settings with generalised epidemics, to reduce the risk of heterosexually acquired HIV infection. |
| Harm reduction for people who use drugs | All people who inject drugs should have access to sterile injecting equipment through needle-and-syringe services. People who are dependent on opioids should be offered and have access to OST. People with harmful alcohol or other substance use should have access to evidence-based interventions, including brief psychosocial interventions involving assessment, specific feedback and advice. People likely to witness an opioid overdose should have access to naloxone and be instructed in its use for emergency management of suspected opioid overdose. Provide interventions that support harm reduction for people who use stimulants, provide safe spaces for drug consumption and means for drug checking. |
| HIV testing and counselling | Voluntary HIV testing and counselling should be routinely offered to all key populations, both in the community and in clinical settings. Community-based HIV testing and counselling for key populations, linked to prevention, care and treatment services, is recommended, in addition to PITC. |
| Treatment and care | All people living with HIV should have the same access to ART and ART management. All pregnant women should have the same access to services for PMTCT and follow the same recommendations. |
| Prevention and management of coinfections and comorbidities | People who use drugs should have the same access to TB prevention, screening and treatment services as other populations at risk of or living with HIV. People who use drugs should have the same access to HBV and HCV prevention, screening and treatment services as other populations at risk of or living with HIV. Routine screening and management of mental health disorders (especially depression and psychosocial stress) should be provided for people from key populations living with HIV to optimise health outcomes and improve their adherence to ART. |
| Sexual and reproductive health | Screening, diagnosis and treatment of STIs should be offered routinely as part of comprehensive HIV prevention and care for key populations. People from key populations, including those living with HIV, should be able to experience full, pleasurable sex lives and have access to a range of reproductive options. Abortion laws and services should protect the health and human rights of all women. It is important to offer cervical cancer screening to all women who use drugs. It is important that all women who use drugs have the same support and access to services related to conception and pregnancy care, as women from other groups. |
ART, antiretroviral therapy; PMTCT, prevention of mother-to-child transmission of HIV; PEP, post-exposure prophylaxis; PrEP, pre-exposure prophylaxis; STIs, sexually transmitted infections; TB, tuberculosis; VMMC, voluntary medical male circumcision; OST, opioid substitution therapy; PITC, provider-initiated testing and counselling; HBV, hepatitis B virus; HCV, hepatitis C virus.
, These interventions are not part of the WHO Framework, but evidence in support of these harm reduction interventions is increasing. Drug checking is most useful to detect contamination with/presence of potent synthetic opioids.
Critical enablers.
| Number | Description |
|---|---|
| 1. | Laws, policies and practices should be reviewed and, where necessary, revised by policymakers and government leaders, with meaningful engagement of stakeholders from key population groups, to allow and support the implementation and scale-up of healthcare services for key populations. |
| 2. | Countries should work towards implementing and enforcing antidiscrimination and protective laws, derived from human rights standards, to eliminate stigma, discrimination and violence against people from key populations. |
| 3. | Health services should be made available, accessible and acceptable to key populations, based on the principles of medical ethics, avoidance of stigma, non-discrimination and the right to health. |
| 4. | Programmes should work towards implementing a package of interventions to enhance community empowerment amongst key populations. |
| 5. | Violence against people from key populations should be prevented and addressed in partnership with key population-led organisations. All violence against people from key populations should be monitored and reported and redress mechanisms should be established to provide justice. |
| 6. | Appropriate funding should be made available to support harm reduction services. |
, This enabler is not part of the WHO Framework, but critical for sustainability and impact.
The screening for substance use and offer of assistance for potentially harmful substance use can take place in a range of clinical scenarios (see
Substance use disorders fall into the category of common mental disorders. Harmful alcohol and other drug use and other mental health disturbance may result in an increased risk of contracting HIV and in substantial health problems amongst people living with HIV. However, it is important to note that most people who use drugs do so on an occasional basis and will not develop a substance use disorder (dependence). For this group, there may be little need for high-intensity interventions. Screening for other common mental disorders including depressive disorders and anxiety disorders should also be performed. These may arise because of psychosocial distress that may be related to the HIV diagnosis or as a consequence of infective processes, which may be primary or secondary in a patient living with HIV. Identification of these is essential as they may impact on clinical outcomes and capacity to adhere to ART. Appropriate treatment is likewise freely available, so there is no need for patients to suffer. Suicidal screening should form part of this assessment because of its association with common mental disorders and the particularly high risk within this population.
Pathways following screening for harmful substance use.
Alcohol, Smoking and Substance Involvement Screening Test risk score and associated risk level and intervention.
| Alcohol | All other substances |
Risk level | Intervention |
|---|---|---|---|
| 0–10 | 0–3 | Lower risk | • General health advice |
| 11–26 | 4–26 | Moderate risk | Brief intervention Take-home booklet and information |
| ≥ 27 | ≥ 27 | High risk | Brief intervention Take-home booklet and information Referral to specialist assessment and treatment |
| Injected drugs in last 3 months |
Moderate and high risk | Information card on risks of injecting Brief intervention Take-home booklet and information Referral to testing for BBVs Referral to specialist assessment and treatment |
|
BBVs, blood-borne viruses; HBV, hepatitis B virus; HCV, hepatitis C virus.
, Tobacco products, cannabis, cocaine, amphetamine-type stimulants, sedatives, hallucinogens, inhalants, opioids and other drugs.
, Need to determine pattern of injecting – injecting more than four times per month (average) over the last 3 months is an indicator of dependence requiring further assessment and treatment.
, Blood-borne viruses including HIV, HBV and HCV.
Behavioural interventions, self-regulation coaching and psychosocial counselling can support HIV harm reduction and other HIV prevention objectives for people who use substances, whilst also contributing to longer-term and broader health and wellness goals.
Key components of brief interventions.
Providing information and feedback about screening results
Understanding the patients’ views of their use and then coaching the patients to change their perceptions about their use
Encouraging the patients to discuss their views on how their use led to their injury, their likes and dislikes about use and how they may consider changing
Advising patients in clear but respectful terms to decrease or abstain from substances
Teaching behaviour change skills that will reduce substance use as well as the chances of negative consequences
Establishing a method for follow-up with the patient; follow-up can be done in another visit or telephonically
Motivational interviewing and adherence.
Brief interventions based on the principles of motivational interviewing (MI), with the possible addition of other complementary approaches such as contingency management (CM), can reduce drug-related high-risk sexual behaviours, increase adherence to ART and maximise PrEP amongst patients who are dependent on stimulant drugs.
ART, antiretroviral therapy; CM, contingency management; MI, motivational interviewing; PrEP, pre-exposure prophylaxis.
Elements of brief interventions may be aligned to the stages as outlined in
Stages of change and recommended brief intervention elements.
| Stage | Definition | Brief intervention elements to be emphasised |
|---|---|---|
| Pre--contemplation | The hazardous or harmful alcohol and/or drug user is not considering change soon, and may not be aware of the actual or potential health consequences of continued risky alcohol and/or drug use | Feedback about the results of the screening and information about the hazards of continued risky alcohol and/or drug use |
| Contemplation | The alcohol and/or drug user may be aware of alcohol and/or drug-related consequences but is ambivalent about making a change | Emphasise the benefits of making a change, give information about problems related to risky alcohol and/or drug use, including the risks of delaying change and discuss how to choose a goal |
| Preparation | The alcohol and/or drug user has already decided to make a change and plans to act | Discuss how to choose a goal, and give advice and encouragement |
| Action | The alcohol and/or drug user has begun to cut down or reduce risky alcohol and/or drug use, but change has not become a permanent feature | Review advice, give encouragement |
| Maintenance | The alcohol and/or drug user has achieved moderate drinking/drug use or abstinence on a relatively permanent basis | Give encouragement and support as required or requested |
Who should screen, provide brief interventions for substance use and refer for care.
| Healthcare worker | Patient encounters and potential scope of work |
|---|---|
| Doctors, nurses, CAs, CHWs, pharmacists, psychologists, counsellors, social workers | Consultations, harm reduction counselling |
| Nurses, CAs | Case management of patients on OST, management of HIV and TB treatment, managing overdose, case management of HBV and HCV |
| Nurses, CAs, CHWs | Case management of patients on HIV, TB, viral hepatitis treatment, managing overdose |
| Doctors, nurses, CAs | Integrated service delivery, management of HIV and TB, managing overdose |
| Doctors | Prescribing and managing patients on OST, withdrawal management, management of viral hepatitis |
| Pharmacists (community- and facility-based) psychologists, counsellors, social workers, CHWs | Supporting patients on OST, HIV, TB, viral hepatitis treatment; needle-and-syringe service |
| Paramedics | Managing emergencies |
| All (including allied health professionals and traditional health practitioners) | Screening, brief interventions and referral for medical and psychosocial services |
CAs, clinical associates; CHWs, community health workers; HBV, hepatitis B virus; HCV, hepatitis C virus; OST, opioid substitution therapy; TB, tuberculosis.
HIV prevention – condoms and lubricant.
| Variable | Description |
|---|---|
| Evidence and implementation experience | The correct and consistent use of male condoms reduces the risk of HIV transmission through anal and vaginal sex by 94% and prevents unintended pregnancy and common STIs. Condom-compatible lubricant (i.e. silicone- or water-based) reduces breakage and slippage. Condoms and lubricant are widely included in harm reduction commodity distribution services – for people who inject drugs, people who use stimulants and for women who use drugs. |
| Main principles | A sufficient quantity of condoms and lubricants (one-to-one ratio) along with counselling around safer sexual practices must form part of the comprehensive harm reduction package for people who use drugs and their sexual partners. |
| Guidelines | Comprehensive condom programming – a guide for resource mobilisation and country programming: |
STIs, sexually transmitted infections.
HIV prevention – pre- and post-exposure prophylaxis.
| Variable | Description |
|---|---|
| Evidence and implementation experience | There is strong evidence showing that, amongst those who are adherent, PrEP is highly effective in reducing HIV transmission through sexual exposure. |
| Main principles | The priority HIV prevention interventions for people who inject drugs remain access to sterile injecting equipment and OST for those who have an opioid dependency. PrEP and PEP are integral parts of packages of care for people who use drugs. PrEP should be offered to people who inject drugs who are interested in PrEP, do not have any contraindications to use, and are at substantial risk for HIV, defined as:
HIV-negative people who inject drugs with HIV-positive/unknown status injecting and/or sexual partner(s) Sharing injecting needles and/or drug preparation equipment People who use/inject drugs and also have risk because of sexual transmission Sexual partners of people who use/inject drugs PEP is the only way to reduce the risk of HIV infection after exposure. PEP should be administered ≤ 72 h after exposure in order for it to be effective, and a full 28 days is required after exposure for full protection. PEP should preferably consist of a combination of tenofovir disoproxil fumarate (TDF) + lamivudine (3TC) or emtricitabine (FTC) and an integrase strand transfer inhibitor (InSTI). Women should be provided with contraception (with due consideration of relevant drug–drug interactions). The regimen for PrEP is most commonly a combination of TDF and FTC. New PrEP options, including injectables, are under development. Requests for PEP should immediately trigger a conversation as to whether the individual should transition to PrEP after completing the 28 days of PEP. Discussions should explore sexual- and drug-use-related risks and use of sterile injecting equipment if appropriate. Regular HIV testing, assessment for HBV, HCV and renal function, and adherence support should all be routine components of PEP and PrEP service provision. Neither PrEP nor PEP is contraindicated for persons with HBV. However, before deciding to stop PrEP or PEP, they should discuss with their provider to avoid experiencing a hepatitis flare. Requests for PrEP and/or PEP should be addressed urgently and diligently, and should be seen as an opportunity to provide an expanded package of care for people who use drugs and allow for access to other important services. These include access to sterile injecting equipment, HIV testing services and other risk reduction interventions. PrEP and PEP only provide protection against HIV. They do not protect against other STIs or other associated health risks that can be addressed by expanded access to care. |
| Guidelines | Southern African guidelines on the safe use of PrEP in persons at risk of acquiring HIV-1 infection: |
3TC, lamivudine; FTC, emtricitabine; InSTI, integrase strand transfer inhibitor; PEP, post-exposure prophylaxis; PrEP, pre-exposure prophylaxis; STIs, sexually transmitted infections; TDF, tenofovir disoproxil fumarate; HBV, hepatitis B virus; HCV, hepatitis C virus; OST, opioid substitution therapy.
HIV prevention – voluntary medical male circumcision.
| Variable | Description |
|---|---|
| Evidence and implementation experience | VMMC reduces the risk of female-to-male HIV transmission by 60% and is recommended as an additional prevention intervention for heterosexually acquired HIV infection in men. |
| Main principles | VMMC should continue to be promoted as an additional efficacious HIV prevention option within combination HIV prevention packages for adolescents aged ≥ 15 years and for adult men in settings with generalised epidemics to reduce the risk of heterosexually acquired HIV infection. |
| Guidelines | South Africa national guidelines for medical male circumcision: |
VMMC, voluntary medical male circumcision.
Harm reduction interventions – needle-and-syringe services.
| Variable | Description |
|---|---|
| Evidence and implementation experience | Needle-and-syringe services, also known as needle-and-syringe programmes, are structured services that allow people who inject drugs to obtain new, sterile needles and syringes and other injecting equipment (including sterile water, alcohol swabs, tourniquets, cookers, etc.) at little or no cost, in order to reduce the risk of HIV and HCV infection. Needle-and-syringe services are the cornerstone of the HIV and viral hepatitis response for people who inject drugs. reduce sharing of needles and unsafe injecting practices by up to 60% decrease HIV transmission by up to 33% – 42% increase contact of healthcare workers with people who inject drugs who would not otherwise access health services in the context of high coverage, and in combination with OST, reduce HCV transmission are some of the most cost-effective public health interventions to date do not increase rates of people starting to inject, nor do they increase frequency of injecting or increase drug use do not decrease motivation to reduce or stop drug use. In 2018, needle-and-syringe services were available in 86 countries. However, the increased circulation of needles and syringes can raise concerns. Occupational needle-stick injuries amongst police during searches and operations are of major concern. Needle-and-syringe services are a crucial gateway to HIV and other services, such as OST, HIV testing and counselling and treatment for HIV, TB and viral hepatitis. |
| Main principles | Denying access to harm reduction services and confiscating injecting equipment have negative health and safety outcomes. These actions increase the likelihood of needle-and-syringe concealment, reuse, sharing and unsafe disposal, increasing the risk of HIV and blood-borne infection transmission to people who inject drugs, the police and general public. People who inject drugs should have access to enough injecting equipment to allow for a new needle/syringe to be used with each injection, along with sterile water and alcohol swabs. Additional materials that reduce risk include cookers and sharps containers. Needle-and-syringe services can be delivered by outreach workers in the community and can also be provided at various points of health service delivery – at visits to general practitioners, hospitals, OST sites, etc. Ideally, sufficient equipment should be provided to prevent needle and syringe re-use. Mechanisms to support safe return of used equipment should be in place, as well as movements towards sharps boxes in community spaces. |
| Guidelines | Implementing comprehensive HIV and HCV programmes with people who inject drugs – practical guidance for collaborative interventions: Guide to starting and managing needle-and-syringe programmes: |
HCV, hepatitis C virus; TB, tuberculosis; OST, opioid substitution therapy; WHO, World Health Organization.
, Guidance on starting a needle-and-syringe services is available at:
Needle-and-syringe services in southern Africa.
By July 2020, needle-and-syringe services existed in nine South African health districts and in Maputo (Mozambique). They were also operational in Mauritius and several countries in East, West and Northern Africa.
Behavioural interventions to support risk reduction.
Interventions should be provided to help people who use drugs to support safer behaviours and sustain positive change. For people who use drugs, recommendations include the following:
involvement of people who use drugs in the development and delivery of messages
interventions need to address risks related to drug use and sexual behaviour
peer interventions are effective for the prevention and management of HIV and HCV
information around safer injecting and drug use, as well as overdose prevention should be provided.
HCV, hepatitis C virus.
Low dead-space syringes.
These syringes have 100-fold less blood in them compared with an ordinary syringe once the plunger has been pushed down fully. This reduces the survival of HIV and HCV within syringes. Where possible, these syringes should be provided, in consultation with needs and preferences of people who inject drugs.
HCV, hepatitis C virus.
Harm reduction interventions – Opioid substitution therapy.
| Variable | Description |
|---|---|
| Evidence and implementation experience | OST is the most effective treatment for opioid dependence. OST is also known as medication-assisted treatment, opioid agonist therapy or, if methadone is used, as methadone maintenance therapy. OST is highly effective in reducing injecting drug use amongst opioid-dependent people, with reduced risks of HIV and HCV transmission. OST improves access and adherence to ART, reduces overdoses and associated mortality, lessens criminal activity and improves the physical and mental health of people with opioid dependency. In 2018, 86 countries were implementing OST. OST (as maintenance) boasts higher retention in treatment and reduced use of un-prescribed opioids than managed withdrawal (detoxification); however, despite the sub-optimal outcomes of the latter, detoxification is still widely used. Clonidine and other non-opioid withdrawal management is sometimes used in practice, but it is not supported by evidence and should be avoided. |
| Main principles | Opioid dependence is a chronic condition, and ongoing recurrence of use is common. An assessment for opioid agonist/substitution therapy for maintenance should be performed in this context. The overall aim of OST is to treat opioid dependence through long-term provision of opioid agonist medications, at appropriate doses. It aims to improve health and well-being by reducing the risk of overdose, preventing cravings and withdrawal, reducing the health consequences of opioid use, and supporting social functioning. Counselling around and referral for voluntary psychosocial services will generally improve the outcomes of people on OST. OST with or without psychosocial support is useful. Clinicians should advocate for access to voluntary psychosocial support if it is needed, especially as it is under-valued and under-resourced by care providers and those providing resources, such as medical aids. The selection between methadone and buprenorphine (±naloxone) is a clinical decision that is made together with the patient after due consideration of: prior response, medical or mental health comorbidity, possible drug interactions, side-effect profile, cost/accessibility, use of other drugs and patient choice. Methadone, buprenorphine and buprenorphine-naloxone are registered for use for OST in South Africa. Efforts are underway to get these medications onto the EML for use at primary care level, OST is most effective as a long-term maintenance treatment at appropriate dosages. OST should be provided for as long as required by the patient. A shorter duration of OST than needed is associated with higher rates of unregulated opioid use and increased risk for HIV and HCV transmission. Opioid withdrawal management (detoxification) should be avoided; it is associated with increased risks of death from overdose, when compared with providing no treatment, and with higher rates of return to use of opioids and increased risk of HIV and HCV transmission, when compared with long-term treatment. If detoxification is performed, then it should be tapered over at least 30 days, paired with intensive psychosocial services, and the person should be switched to OST if they are not able to be abstinent. Rapid tapering of opioid agonists (< 1 week) is contraindicated. Inpatient care for OST is required for a very small minority of patients; outpatient care is practical, safe and often successful and less costly. |
| Best practices | |
| Guidelines | Detailed guidance on OST is provided in The National Department of Health is developing national guidelines for OST South African guidelines for the management of opioid use disorders: Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence: |
ALT, alanine transaminase; ART, antiretroviral therapy; AST, aspartate transaminase; ECG, electrocardiogram; EML, essential medicines list; FBC, full blood count; HBsAg, hepatitis B surface antigen; HCV, hepatitis C virus; OST, opioid substitution therapy; TB, tuberculosis; QTc, corrected QT interval; WHO, World Health Organization.
, Methadone is included in the South African EML for opioid detoxification in hospital settings.
Testing for the presence of drugs in urine or other fluids.
Testing the presence of drugs in urine or other bodily fluids may be helpful to assist with diagnosis. Different views on the use of repeated drug testing exist. Testing is frequently used as a punitive measure and done in a way that violates the patient’s autonomy and dignity.
EFV, efavirenz.
Regulation of opioid substitution therapy medications and diversion.
Any doctor can prescribe OST. The quality of care and retention of patients can be improved through training. The scheduling of opiates means that prescribing is highly regulated, and close communication between the prescriber, the pharmacist and the person collecting the prescription requires active coordination. Diversion of OST medications at the patient level is an area of concern, but rarely a problem. However, the risk-benefit of take-home doses versus strict, continuous daily observed treatment are in favour of supported take-home doses. Diversion is usually an indication of limited access to OST. Patients on OST may share their medications with others as an act of solidarity and support.
OST, opioid substitution therapy.
Stimulant drug use by people on opioid substitution therapy.
People on OST may use stimulants because of OST-triggered fatigue, inability to experience pleasure or the desire to remain connected to the community of people who use drugs. Opioid substitution therapy is not designed to counter stimulant use, and the concurrent use of stimulants whilst on OST should not be viewed as a breach of treatment agreement and should not result in the reduction or discontinuation of OST. The benefits of OST are independent of stimulant use and limiting access to OST because of stimulant use denies the individual of the much-needed medication and is in contravention of the UNODC TreatNet principles.
OST, opioid substitution therapy; UNODC, United Nations Office on Drugs and Crime.
Opioid substitution therapy and overdose risk.
The risks of opioid overdose need to be known by patients and healthcare providers. Training on the use of naloxone is recommended, with take-home naloxone for all patients on OST. See section ‘Overdose services’ for additional details.
OST, opioid substitution therapy.
Opioid substitution therapy for special populations.
Treatment is more complex in children and adolescents, pregnant or breastfeeding women, patients with significant medical comorbidity (e.g. hepatic impairment, HIV, TB and complex psychiatric pathology) and in patients with chronic pain who are dependent on prescription opioids. It is recommended that such patients be managed together with a specialist in the treatment of opioid use disorders.
TB, tuberculosis.
Management of acute pain in opioid use disorders.
Patients with acute pain and opioid use disorders can be challenging to manage, partly because of central sensitisation, tolerance and opioid-induced hyperalgesia.
Note:
Pain is not controlled with methadone or buprenorphine for OST as it is dosed daily and the analgesic effect only lasts 4–8 h
There is no evidence that exposure to opioid analgesics in the presence of acute pain increases rates of reuse of illicit opioids
The additive effects of opioid analgesics and OST have not been shown to cause clinically significant respiratory or central nervous system depression
Reports of acute pain with objective findings are unlikely to be manipulative gestures
Additional guidance is provided in
OST, opioid substitution therapy.
Harm reduction interventions – Overdose services.
| Variable | Description |
|---|---|
| Evidence and implementation experience | Globally, an estimated 167 750 deaths were directly associated with drug use in 2018; 76% of these were because of opioid use. |
| Managing opioid overdose | Pinpoint pupils Unconsciousness Respiratory depression (bradypnoea) (< 10 breaths per minute or 1 breath every 5 s) Patients may also have blue lips or fingernails, snoring/gasping and pale/clammy skin. S – stimulation (wakening) C – call for medical help A – airway R – rescue breathing E – evaluate breathing and response M – muscular injection of naloxone E – evaluate and support Standard resuscitation procedures should be carried out. Patients should then be considered for naloxone injection and referral for further management, if warranted. Using naloxone: Route of administration is based on the formulation available, skills in administration and the local context. Naloxone injection is available for SC, IM or IV injection or for IV infusion. Intramuscular naloxone may result in a more rapid clinical response. Intramuscular injection should be into a large muscle, preferably the deltoid or quadriceps muscle. In most cases 0.4 mg – 0.8 mg is an effective dose, with repeated doses as needed. |
| 2. Managing overdose because of benzodiazepines |
History of sedative use Presents drowsy, confused, pupils normal Check airway, breathing, circulation Provide respiratory support and give oxygen Administer flumazenil (0.2 mg IV over 15–30 s)
If no response after 30 s, then administer 0.3 mg over 30 s, 1 min later If no response, then repeat dose of 0.5 mg IV over 30 s at 1-min intervals to a maximum cumulative dose of 3 mg/h In the event of re-sedation, may repeat dose at 20-min intervals if needed; do not exceed 1 mg (administered as 0.5 mg/min) administered at any one time and no more than 3 mg/h Rarely, patients may require titration up to a total dose of 5 mg: if no response after 5 min, then sedation is unlikely to be secondary to benzodiazepines Administer naloxone if opioid use cannot be excluded and observe response
Exclude other medical causes of confusion/sedation. |
| 3. Managing stimulant overdose/intoxication |
History of stimulant use Mild to moderate cases: dilated pupils, excited, racing thoughts, disordered thinking, strange behaviour, increased body temperature, flushed face, muscle cramps and stiffness Severe cases: unresponsive, arrhythmias, circulatory and respiratory collapse, hypertension, tachycardia, fever, increased motor activity, seizure, confusion Mild to moderate cases: observation, supportive management Severe cases:
Treat with diazepam 5 mg – 10 mg PO, IV or PR until patient is lightly sedated If psychotic symptoms do not respond, then consider anti-psychotic (e.g. haloperidol 1.0 g – 2.5 g PO or IM); refer to psychiatry as needed In hospital: control seizures, treat cardiac complications, control blood pressure and temperature, secure IV access and correct any electrolyte imbalance |
| Guidelines | The WHO Mental Health Gap Action Programme (mhGAP) intervention guide for mental, neurological and substance use disorders in non-specialised health settings: |
IM, intramuscular; IV, intravenous; PO,
Algorithm for managing sedative or stimulant overdose.
Opioid overdose prevention and reversal.
Overdose can be both prevented and treated, thus staff in services working with people who inject drugs have an essential role in overdose prevention and management. Prevention interventions include:
Education around overdose risks targeting people who use opioids
Means to check the quality and purity of drugs using point of care drug testing kits by people who use drugs (see more in section ‘Emerging and ancillary interventions’)
Drug consumption rooms/safe injecting facilities† (see more in Section ‘Drug consumption rooms’)
Opioid substitution therapy services (see more in
Training around first responses and opioid overdose reversal using naloxone
Expanding access to naloxone for overdose response:
Availability in community pharmacies, without a script People likely to witness or respond to an overdose need to be trained in identification of overdose, naloxone administration and patient support and be provided with naloxone – these include ambulance, police and fire fighters, people who use opioids, people on OST and their family members or support people
OST, opioid substitution therapy.
†, It is noteworthy that no fatal overdoses have been reported in any of the countries, which implement safe injecting facilities.
Naloxone.
This opiate antagonist reverses the effects of an opioid overdose, with a half-life of approximately 45 min. It is recommended by the WHO and is included in South Africa’s EML for use at primary level. The most distributed form is liquid naloxone for injection. It is also available as an auto-injectable or as a nasal spray (although these are not available locally). Like insulin for diabetes, naloxone can be administered safely by a lay person with very basic training.
EML, essential medicines list; WHO, World Health Organization.
Management of withdrawal for other substances.
People experiencing withdrawal symptoms have developed dependence and should be referred for voluntary psychosocial services, and in some instances, medical treatment.
Stimulants
Admission is usually not required Beware of depression and assess suicide risk and psychosis No substitution available; for severe symptoms provide 5–7 days of benzodiazepines
Methaqualone
Withdrawal can lead to seizures or delirium; treat if symptomatic with diazepam (oral 5 mg 8-hourly, reducing over 3–5 days)
Benzodiazepines
Avoid abrupt withdrawal; reduction takes time; patients require monitoring and motivation Replace short-acting benzodiazepine with longer-acting benzodiazepine
Several additional interventions are important as part of comprehensive harm reduction. Some are briefly provided below, including (1) harm reduction for people who use stimulants, (2) drug consumption rooms and (3) drug checking services.
Simple harm reduction advice for people who use stimulants is to follow a few steps.
Avoid the concurrent use of alcohol and cocaine. Cocaine use potentially compromises the cardiovascular system and is linked to several cardiovascular diseases; this risk increases with the concurrent use of alcohol.
Other relevant harm reduction interventions include psychosocial support, condoms and lubricants (amphetamine-type stimulants can increase sex drive and risky sexual practice) and drug paraphernalia distribution (injecting and/or smoking kits that include mouth pieces for crack pipes), services for sexually transmitted infections, income generation and housing support. Substitution therapies for stimulant use disorders are under investigation.
Resources on harm reduction for stimulant use.
Guidance for general practitioners working with people who use stimulants:
HIV prevention, treatment, care and support for people who use stimulant drugs:
A community-based site with details about drug compositions and harm reduction:
Harm reduction requires engaging with patients to identify immediate risks and develop means to reduce these.
Screening, brief intervention and referral for treatment is an effective approach to detect and intervene in harmful substance use.
Needle-and-syringe services are the cornerstone of HIV prevention for people who inject drugs and should be provided at all contacts with health services.
People who inject drugs should be supported to return their used injecting equipment and locations for safe disposal of used equipment should be made widely available.
Opioid substitution therapy is the most effective treatment for opioid use disorder. Effectiveness is maximised when patients are supported and provided with an optimal dose of medication. Voluntary psychosocial services can improve outcomes. Safety risks are greatest early on during treatment, and patients who are stable should be considered for take-home dosing. Treatment should be long term.
Good supply chain and stock management are important to minimise diversion of opioid agonist medications.
Opioid overdoses cause many deaths and are preventable. People likely to witness an opioid overdose should be trained to identify and respond to this, and access to naloxone should be maximised.
HIV testing treatment and care – HIV testing and counselling.
| Variable | Description |
|---|---|
| Evidence and implementation experience | People who use drugs are at risk of exposure to HIV and other STIs, owing to the drugs’ effects on the brain that may alter judgement and decision-making. The use of drugs, including alcohol, opioids, methamphetamine and other stimulants has demonstrated its influence on risky behaviours such as increased drive for, amongst others, sex, multiple sexual partners and unprotected sex. HTS can be an entry point to HIV and viral hepatitis prevention and treatment services. Combining counselling with knowledge of a person’s HIV and HCV status can help link people to harm reduction services. |
| Main principles | HTS may be provided in a variety of settings, including along outreach routes, in mobile units or temporary testing sites, at drop-in centres, needle-and-syringe services sites and dedicated HTS and health facilities. HTS services should also be provided to patients within detention settings as well as within prison. HTS can be either with finger-prick or oral swab samples. Oral swabbing may be more acceptable to people who inject drugs, in whom it may be difficult to access venous blood. In some settings, this might mean providing services during evening hours or weekends, or at home through self-testing (described below). The provision of integrated services removes some of the perceived barriers to HIV testing for people who use drugs and is cost-saving. HIV services need to be especially ‘friendly’ to youth and women who use drugs. Social mobilisation and educational initiatives amongst networks of people who use drugs should be performed to encourage service uptake. |
| Approaches for systematic scale-up | |
| Guidelines | South African HIV self-testing policy and guidance considerations: National HIV self-screening guidelines: WHO recommendations for HIV testing by lay providers (2015): |
HCV, hepatitis C virus; HTS, HIV testing services; STI, sexually transmitted infection; TB, tuberculosis; OST, opioid substitution therapy; PICT, provider-initiated counselling and testing.
HIV testing treatment and care – antiretroviral therapy.
| Variable | Description |
|---|---|
| Evidence and implementation experience | Despite stereotypes, with adequate social support and allied medical services, people who use drugs have levels of viral suppression that are similar to other groups of people. |
| Main principles | People who use drugs and who are found to be HIV-positive should be offered immediate treatment or referral for long-term care and treatment, preferably at a clinic or hospital whose staff are respectful of everyone and diversity of choice. Community-based case management or peer navigation could facilitate treatment initiation and adherence support for people who use drugs. ART choices for common first-line regimens, including DTG are conventional and should follow national guidelines. As a result of potential drug–drug interactions, care should be taken when using the NNRTIs, especially EFV and NVP, as well as the NRTI, ABC, with methadone and buprenorphine; TDF, 3TC and RPV may be the safer drugs to use. PIs have many drug interactions with other medications, notably methadone, buprenorphine and psychiatric medications. |
| Guidelines | ART clinical guidelines for the management of HIV in adults, pregnancy, adolescents, children, infants and neonates (2019): HIV drug interactions checker: |
3TC, lamivudine; ABC, abacavir; ART, antiretroviral therapy; EFV, efavirenz; DTG, dolutegravir; NNRTIs, non-nucleoside reverse transcriptase inhibitors; NRTI, nucleoside reverse transcriptase inhibitor; NVP, nevirapine; PIs, Protease inhibitors; RPV, rilpivirine; TDF, tenofovir disoproxil fumarate.
HIV testing treatment and care – prevention of mother-to-child transmission of HIV.
| Variable | Description |
|---|---|
| Evidence and implementation experience | PMTCT should involve:
Primary prevention of HIV infection amongst women of child-bearing age Prevention of unintended pregnancies amongst women of child-bearing age living with HIV Prevention of HIV transmission from women living with HIV to their infants Provision of treatment, care and support to mothers living with HIV and their children and families |
| Main principles | PMTCT services should follow national guidelines. Women who use drugs experience additional barriers to accessing HIV services; special efforts are needed to understand and overcome these barriers. Additional information and guidance are provided in section ‘Women who use drugs’. |
| Guidelines | SAHCS Guidelines to support HIV-affected individuals and couples to achieve pregnancy safely: Update 2018, found here: South African National Department of Health 2019 Guideline for the Prevention of Mother to Child Transmission of Communicable Infections (March 2020 update) |
PMTCT, prevention of mother-to-child transmission of HIV; SAHCS, Southern African HIV Clinicians Society.
People who use drugs should be informed of their rights to confidentiality and consent and their right to refuse HIV testing if they choose.
Uptake and retention in care are improved where ART is integrated with OST when needed.
Pregnant women living with HIV who are not on ART should be enrolled on an ART programme urgently.
Needle-and-syringe programmes and other evidence-based harm reduction services should be offered to all people who use drugs, irrespective of their HIV status.
All people who use drugs and who are found to be HIV-negative should be provided with risk reduction information and commodities tailored to their substance use (considering their patterns and type of substance, etc.) and sexual practices.
People who use drugs and who test HIV-negative should test regularly (every 6 weeks to 3 months) depending on their risk profile.
An individual with a discrepant HIV test result should be referred for re-testing in 14 days.
If a person comes for HTS within 72 h after a potential exposure, then PEP should be considered
Tuberculosis services.
| Variable | Description |
|---|---|
| Evidence and implementation experience | TB is frequently underdiagnosed amongst people who use drugs, particularly amongst people who use or inject heroin. |
| Main principles | Chest X-rays should be considered in addition to TB symptom screening to rule out active TB amongst people who use drugs. In general, TB treatment and services are conventional. The propensity for TB drugs to have overlapping toxicity with other conditions with hepatic impact, such as HBV and HCV, and the medications used for treating these, means that careful counselling and follow-up should be available. Rifampicin can reduce the concentration and effect of heroin, methadone and buprenorphine, triggering opioid withdrawal and should be discussed as part of counselling. People who use drugs may have dysfunctional immune systems because of their drug use, and the inflammatory changes may mean that responses to TB treatment may be more unpredictable. Clinicians should pay close attention to these patients, especially with regards to any new symptoms. TB is often a marker of poor socio-economic status and, in the context of drug use, should trigger intensive and appropriate social, community and nutritional support. Ongoing drug use is not a contraindication to TB treatment. Clinicians should be aware that engaging with patients around ways to complete TB treatment and modify/adapt substance use patterns will likely result in higher treatment completion rates, compared with expectations of abstinence. Where possible, OST should be offered to people with opioid dependence and should be co-administered with TB treatment. |
| Guidelines | Integrating collaborative TB and HIV services within a comprehensive package of care for people who inject drugs: |
TB, tuberculosis; HBV, hepatitis B virus; HCV, hepatitis C virus; OST, opioid substitution therapy.
Viral hepatitis services.
| Variable | Description |
|---|---|
| Evidence and implementation experience | The risk of HCV infection amongst people who inject drugs is high where access to sterile injecting equipment and OST is limited. Regular HCV testing should be conducted in people who use drugs. Antibody testing is the first step for people of unknown status. Those who have resolved their infection or have been treated should receive follow-up testing for HCV RNA. Cure rates with DAAs – measured as sustainable virological response – amongst people who inject drugs are > 90% in most cases. All people who are infected with HCV are candidates for treatment. |
| Main principles | Hepatitis prevention (including vaccination for HBV) testing and treatment should be integrated into services for people who use drugs. An alcohol intake assessment should be performed amongst patients with chronic HCV infection, linked to a brief intervention and further management as needed. Counselling around risk reduction to avoid HCV re-infection amongst people who inject drugs is important, as well as the provision/referral to access sterile injecting equipment and OST (for people who inject opioids). In HIV/HCV co-infected patients, potential interactions exist with ART medications for HIV treatment and DAAs for the treatment of HCV, sometime requiring altering of DAA dose. Screening for HBV infection should include assessment of HBsAg. Work-up and management for HBV infection is the same for all population groups. People with HBV-HCV co-infection should be managed by a specialist. |
| Approaches for systematic scale-up | HCV treatment services are restricted to academic treatment centres, and selected private providers, largely because of the cost of the drugs and relatively small numbers of patients. Advocacy efforts will be required to scale up these services and to reduce costs. HBV services should be integrated into existing services and uncomplicated cases should be managed at the primary care level. |
| Best practice/specific guidelines | National Department of Health clinical guidelines for the management of viral hepatitis: University of Liverpool website and app for selected DAA therapy: Guidance on the prevention of HBV and HCV amongst people who use drugs: Guidelines for the care and treatment of persons diagnosed with chronic HCV infection: Guideline for the management of HIV/HBV co-infection: South African guideline for the management of chronic hepatitis B (2013): |
DAAs, direct-acting antivirals; HBV, hepatitis B virus; HCV, hepatitis C virus; RNA, ribonucleic acid; OST, opioid substitution therapy; ART, antiretroviral therapy.
Mental health services.
| Variable | Description |
|---|---|
| Evidence and implementation experience | Common mental health disorders, including depression, anxiety and substance use disorders are twice as common in people living with HIV than in the general population and are also elevated amongst people with substance use disorders. |
| Main principles | Screening patients to identify harmful/risky substance use for mental disorders is crucial. Untreated substance use disorders and mental disorders, particularly amongst people living with HIV, may result in HIV treatment being less effective owing to compromised adherence and on-going risky behaviour. Presentation varies from physical complaints to behavioural disturbance such as social withdrawal, aggression or violence and may result in sub-optimal adherence and HIV disease progression. The availability of appropriate treatment and better known outcomes associated with early intervention means that these health problems can and should be addressed timeously to improve the likelihood of better outcomes in HIV treatment. Screening should always be carried out with due consideration of appropriate referral and follow-up. Addressing the potential risks associated with the interrelationship of drug use and HIV requires a multipronged, individualised approach. These include interventions such as MI, CM and CBT, based on the principles of individual and community inclusion and participation, peer support and the needs of the individual. Psychosocial interventions improve retention in ART compared with no intervention. Be aware of drug–drug interactions between psychiatric medications and OST. Where referral for additional assessment is warranted, this is carried out in accordance with the |
| Guidelines and resources | Mental health information centre of southern Africa: South African Depression and Anxiety group: Materials for the provision of psycho-education for mental disorders via the Mental Health Innovation Network: mhGAP intervention guide: |
ART, antiretroviral therapy; CBT, cognitive behavioural therapy; CM, contingency management; MI, motivational interviewing; OST, opioid substitution therapy.
Sexual and reproductive health services.
| Variable | Description |
|---|---|
| Evidence and implementation experience | The SRH of people who use drugs is often overlooked by healthcare providers. All people should be able to enjoy pleasurable sexual lives and have equal access to SRH services and rights. |
| Main principles | Screening, diagnosis and treatment of STIs should be provided routinely. Clinicians should be able to have open and honest discussions with people who use drugs, around sexual practices and risks, including high-risk practices (e.g. unprotected anal or vaginal intercourse and multiple partnerships) and around sex work. Contraceptive services should be offered to women who use drugs. Women who use opioids should be informed about the influence of opioids on menstruation and the potential for pregnancy in the absence of contraception. There are no clinically significant drug interactions with opioid agonist medications and hormonal contraceptives. Dual contraception methods should be advised to women at high risk for HIV. Clinicians should provide termination of pregnancy services aligned with local guidelines. Women who use drugs may not actively engage in healthcare services, so cervical cancer screening should be integrated into harm reduction service delivery. Support and care should be provided to women who use drugs during conception and care. |
| Guidelines and resources | UNODC guidelines on drug prevention and treatment for girls and women (2016): WHO guidelines for the identification and management of substance use and substance use disorders in pregnancy (2014): |
SRH, sexual and reproductive health; STIs, sexually transmitted infections; UNODC, United Nations Office on Drugs and Crime; WHO, World Health Organization.
Clinicians, programme managers and policymakers should work together to support the decriminalisation of drug use, as well as sex work, to reduce health risks related to arrest, detention and incarceration and ensure the protection of rights.
Interventions and support to reduce drug dependence should ideally consist of a continuum of care, starting with early development strategies focusing on the delay of drug use and prevention strategies, moving to early-use interventions such as brief interventions and information. More intensive interventions should be reserved for people with dependencies that cause significant impairment.
Clinicians should take on an advocacy role for: better care based on evidence for people who use drugs; human rights for people who use drugs; harm reduction approaches that include the activities described earlier, as well as access a safe supply of opioids (see the text
Clinicians and public health leaders should work with civil society organisations and networks of people who use drugs to monitor stigma and discrimination and advocate to change punitive legal and social norms. The development of a stigma index that includes people who use drugs and other people engaged in illegal and/or stigmatised practices could be developed to quantify stigma and measure changes over time.
Decriminalisation.
Several nations are experimenting with decriminalisation of drug use or possession for personal use (e.g. Portugal) with significant improvements in public health, particularly around HIV and other health conditions.
Safe supply interventions.
These interventions aim to address the harms related to contaminated drug supply and remove the risks associated with unknown strength of substances and potential toxicity of additional substances. These interventions provide alternatives to street-level drugs. Such programmes exist in Canada and include the prescription by doctors of hydromorphone and diacetylmorphine for people who use opioids.
Clinicians should ensure that the health services they provide are available, accessible and acceptable to people who use drugs.
Approaches to rendering services friendly to people who use drugs and other key populations:
Ensuring adequate training of staff and develop supportive attitudes towards people who use drugs
Integrating health services
Providing services at times that suit patients
Locating services strategically where patients congregate or transit
Involving peers in the planning, promotion, delivery and monitoring of services
Taking steps to ensure law enforcement does not interfere with access to services
Clinicians, public health leaders and civil society organisations can support the empowerment of people who use drugs by enabling their active participation in the planning and implementation of services, with a focus on peer education and training on safer drug use, harm reduction and broader issues relating to their rights and health.
People who use drugs are at high risk for physical, sexual and psychological violence. This violence increases their risk for HIV and viral hepatitis and negatively affects their mental health. Many people who use drugs have been traumatised through their engagement with law enforcement and entry into the criminal justice system. Women who use drugs are at particularly high risk of violence and its effects.
Clinicians, public health leaders and civil society organisations should aim to prevent violence affecting people who use drugs, which can include engagement with law enforcement to sensitise them to the issues and their role to uphold the rights of all people.
The occurrence of violence should also be monitored and reported and mechanisms to access redress explored.
Clinicians should provide clinical care and initial psychological support to survivors of violence, with referral for additional support when needed. Processes following instances of rape should follow local guidelines.
There is strong evidence linking structural inequities to accessing health services with a higher risk of HIV infection, as well as continuing or everyday intimate partner- and gender-based violence.